<div class="dashboard-wrapper">
    <div class="left-sidebar" style="margin-right: 0px;">

        <div class="row-fluid">
            <div class="span12">
                <div class="widget">
                    <div class="widget-header">
                        <div class="title">
                            Form nhập liệu
                        </div>

                    </div>
                    <div class="widget-body">

                        <form class="form-horizontal no-margin">
                            <div class="control-group">
                                <label for="name" class="control-label">
                                    Tên nhà cung cấp
                                </label>
                                <div class="controls">
                                    <input value="Công ty A" type="text" placeholder="Tên vật tư" class="span6" id="email1" name="email1">
                                </div>
                            </div>
                            <div class="control-group">
                                <label for="country" class="control-label">
                                    Nhóm sản phẩm dịch vụ
                                </label>
                                <div class="controls">
                                    <select class="span6" id="stateAndCity">

                                        <option value="">
                                            Chọn nhóm sản phẩm dịch vụ
                                        </option>

                                        <option selected="selected" value="AL">
                                            BTT
                                        </option> 
                                        <option value="AL">
                                            NTT
                                        </option>
                                    </select>
                                </div>
                            </div>
                            <div class="control-group">
                                <label for="name" class="control-label">
                                    Địa chỉ
                                </label>
                                <div class="controls">
                                    <input value="3/2A Cộng Hòa,HCM " type="text" placeholder="3/2A Cộng Hòa,HCM" class="span6" id="email1" name="address">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">
                                    Số điện thoại
                                </label>
                                <div class="controls">
                                    <input type="text" placeholder="Phone" class="span4" value="0123456789">
                                    <span class="help-inline ">
                                        Enter your Phone Number
                                    </span>
                                </div>
                            </div>
                            <div class="control-group">
                                <label for="name" class="control-label">
                                    Email
                                </label>
                                <div class="controls">
                                    <input value="hoaphat@gmail.com" type="text" placeholder="hoaphat@gmail.com" class="span6" id="email1" name="email">
                                </div>
                            </div>
                            <div class="control-group">
                                <label for="name" class="control-label">
                                    Fax
                                </label>
                                <div class="controls">
                                    <input value="084.0123456789" type="text" placeholder="084.0123456789" class="span6" id="email1" name="fax">
                                </div>
                            </div>
                            <div class="control-group">
                                <label for="name" class="control-label">
                                    Website
                                </label>
                                <div class="controls">
                                    <input value="hoaphatservice.com.vn" type="text" placeholder="hoaphatservice.com.vn" class="span6" id="email1" name="website">
                                </div>
                            </div>

                            <div class="control-group">
                                <label for="repPassword" class="control-label">
                                    Ghi chú
                                </label>
                                <div class="controls">
                                    <textarea placeholder="Ghi chú" class="input-block-level span6" name="description3" id="description3" rows="3">Lấy ra phần ghi chú nếu có...</textarea>
                                </div>
                            </div>
                            
                            
                            <div class="form-actions no-margin">

                                <button style="margin-left: 5px;" class="btn btn-info pull-right" type="submit">
                                    Sửa
                                </button>

                                <a href="nha-cung-cap.html" class="btn btn-info pull-right" type="submit">
                                    Trở lại
                                </a>
                                <div class="clearfix">
                                </div>
                            </div>

                        </form>

                    </div>
                </div>
            </div>

        </div>






    </div>

</div>